Youth & Teen Program Form

Youth Program Membership Form

Complete the form below to register your child(ren) for our Youth Programs, including Kadima, Junior/Senior USY, and Camp Yofi CITs.

Step 1 of 5

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Parent/Guardian #1 Information

Parent/Guardian #1 Name*

FirstLast

Parent/Guardian #1 Address*

Street AddressAddress Line 2CityStateZIP Code

Parent/Guardian #1 Home Phone*

Parent/Guardian #1 Cell Phone*

Parent/Guardian #1 E-mail*

Are you able to help drive carpools to/from offsite programming?*

Yes

No

Are you interested in hosting programming at your residence?*

Yes

No

Would you like to add a second parent/guardian?*

Yes

No

Parent/Guardian #2 Information

Parent/Guardian #2 Name*

FirstLast

Parent/Guardian #2 Address*

Street AddressAddress Line 2CityStateZIP Code

Parent/Guardian #2 Home Phone*

Parent/Guardian #2 Cell Phone*

Parent/Guardian #2 E-mail*

Are you able to help drive carpools to/from offsite programming?*

Yes

No

Are you interested in hosting programming at your residence?*

Yes

No

Participant #1 Information

Participant #1 Name*

FirstLast

Hebrew Name

Participant #1 Address*

Street AddressAddress Line 2CityStateZIP Code

Participant #1 Home Phone*

Participant #1 Cell Phone*

Participant #1 E-mail

School*

Grade*

Select Youth Program*

4th-6th Grade Youth Program -Temple Aliyah Member - $75

4th-6th Grades Youth Program - Non-Member - $125

7th-8th Grade Teen Program - Temple Aliyah Member - $125

7th-8th Grade Teen Program - Non-Member - $175

9th-12th Grade Teen Program - Temple Aliyah Member - $125

9th-12th Grades Teen Program - Non-Member - $175

Disneyland Day 2014 (Grades 4-12)*

Yes, I would like to go to Disneyland on August 3 - $90

No, I am not interested in going to Disneyland - $0

Medical/Transportation Form for Participant 1

I/we understand that if my child/teen is present at any KADIMA/USY/CIT event, that he/she is attending with my/our consent and permission to the Youth Department and its employees and agen ts to take my children on field trips and programs; and do hereby release its agents, officers, and employees from any and all liability arising from my/our child's/teen/s participation. In case of accident/illness, the Youth Department representatives have my permission to obtain proper aid (hospitalization, x-ray, etc.) deemed necessary by a doctor and I/we agree to pay all expenses incurred. Every attempt will be made to reach the child's parents and/or doctor for any emergency arising.*

Type your name in the box above for your electronic signature.

Medical Insurance Company*

Policy/Group Number*

Insurance Company Address*

Street AddressAddress Line 2CityStateZIP Code

Insurance Company Phone*

Personal Physician Name*

FirstLast

Personal Physician Phone*

The information on this form is accurate, complete, and all-inclusive, to the best of my knowledge. I understand the importance of keeping this information accurate and agree to contact the Temple Aliyah Director of Youth and Teen Engagement prior to any program my child/teen will attend if there is a change of any kind whatsoever in his/her medical condition.*

Type your name in the box above for your electronic signature.

List all medications currently taken on a regular basis and reasons for taking:*

Explain all other medical problems/conditions of which we should be aware:*

List any allergies to food, drugs, plants, insects, etc.:*

I acknowledge and accept USY/KADIMA/CIT's policies to use licensed drivers over the age of 21 at all times. With full understanding of the policy and the risks involved, I give permission for my child/teen to ride in a proply insured vehicle driven by a licensed driver over the age of 21.*

Type your name in the box above for your electronic signature.

I consent and give permission for my USYer/KADIMAnik/CIT to attend and participate in all trips and activities arranged by Temple Aliyah and Far West USY/KADIMA/CIT for which he/she is registered. I certify that my USYer/KADIMAnik/CIT is physically and psychologically able to participate in all such activities. In case of emergency, I authorize you, as my agent, and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe and/or direct administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions.*

Type your name in the box above for your electronic signature.

I expressly release and indemnify Temple Aliyah and it's officers, directors, agents and employees, and hold Temple Aliyah and its officers, directors, agents and employees free and harmless, from any and all liability, charged, claims, costs and expenses of eery kinds and nature whatsoever, including reasonable attorney fees, in connection with acceptance and participation of my USYer/KADIMAnik/CIT in Temple Aliyah's activities. This release and indemnification is unconditional and without reservations of any kind for such acts or omissions that arise out of your intentional or negligent wrongdoing, and where there is no fault by my USYer/KADIMAnik/CIT. I am fully responsible if I fail to disclose any pertinent information.*

Type your name in the box above for your electronic signature.

I allow Temple Aliyah to use any photographs/videos of my children taken during any Temple Aliyah/Far West USY sponsored programs/events for usage in promotional aspects.

Optional: Type your name in the box above for your electronic signature.

Would you like to add a second participant?

Yes

No

Participant #2 Information

Participant #2 Name*

FirstLast

Hebrew Name

Participant #2 Address*

Street AddressAddress Line 2CityStateZIP Code

Participant #2 Home Phone*

Participant #2 Cell Phone*

Participant #2 E-mail

School*

Grade*

Select Youth Program*

4th-6th Grade Youth Program - Temple Aliyah Member - $75

4th-6th Grade Youth Program - Non-Member - $125

7th-8th Grade Teen Program - Temple Aliyah Member - $125

7th-8th Grade Teen Program - Non-Member - $175

9th-12th Grade Teen Program - Temple Aliyah Member - $125

9th-12th Grade Teen Program - Non-Member - $175

Disneyland Day 2014 (Grades 4-12)*

Yes, I would like to go to Disneyland on August 31 - $90

No, I am not interested in going to Disneyland - $0

Medical/Transportation Form for Participant 2

I/we understand that if my child/teen is present at any KADIMA/USY/CIT event, that he/she is attending with my/our consent and permission to the Youth Department and its employees and agen ts to take my children on field trips and programs; and do hereby release its agents, officers, and employees from any and all liability arising from my/our child's/teen/s participation. In case of accident/illness, the Youth Department representatives have my permission to obtain proper aid (hospitalization, x-ray, etc.) deemed necessary by a doctor and I/we agree to pay all expenses incurred. Every attempt will be made to reach the child's parents and/or doctor for any emergency arising.*

Type your name in the box above for your electronic signature.

Medical Insurance Company*

Policy/Group Number*

Insurance Company Address*

Street AddressAddress Line 2CityStateZIP Code

Insurance Company Phone*

Personal Physician Name*

FirstLast

Personal Physician Phone*

The information on this form is accurate, complete, and all-inclusive, to the best of my knowledge. I understand the importance of keeping this information accurate and agree to contact the Temple Aliyah Director of Youth and Teen Engagement prior to any program my child/teen will attend if there is a change of any kind whatsoever in his/her medical condition.*

Type your name in the box above for your electronic signature.

List all medications currently taken on a regular basis and reasons for taking:*

Explain all other medical problems/conditions of which we should be aware:*

List any allergies to food, drugs, plants, insects, etc.:*

I acknowledge and accept USY/KADIMA/CIT's policies to use licensed drivers over the age of 21 at all times. With full understanding of the policy and the risks involved, I give permission for my child/teen to ride in a proply insured vehicle driven by a licensed driver over the age of 21.*

Type your name in the box above for your electronic signature.

I consent and give permission for my USYer/KADIMAnik/CIT to attend and participate in all trips and activities arranged by Temple Aliyah and Far West USY/KADIMA/CIT for which he/she is registered. I certify that my USYer/KADIMAnik/CIT is physically and psychologically able to participate in all such activities. In case of emergency, I authorize you, as my agent, and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe and/or direct administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions.*

Type your name in the box above for your electronic signature.

I expressly release and indemnify Temple Aliyah and it's officers, directors, agents and employees, and hold Temple Aliyah and its officers, directors, agents and employees free and harmless, from any and all liability, charged, claims, costs and expenses of eery kinds and nature whatsoever, including reasonable attorney fees, in connection with acceptance and participation of my USYer/KADIMAnik/CIT in Temple Aliyah's activities. This release and indemnification is unconditional and without reservations of any kind for such acts or omissions that arise out of your intentional or negligent wrongdoing, and where there is no fault by my USYer/KADIMAnik/CIT. I am fully responsible if I fail to disclose any pertinent information.*

Type your name in the box above for your electronic signature.

I allow Temple Aliyah to use any photographs/videos of my children taken during any Temple Aliyah/Far West USY sponsored programs/events for usage in promotional aspects.

Optional: Type your name in the box above for your electronic signature.

Would you like to add a third participant?

Yes

No

Participant #3 Information

Participant #3 Name*

FirstLast

Hebrew Name

Participant #3 Address*

Street AddressAddress Line 2CityStateZIP Code

Participant #3 Home Phone*

Participant #3 Cell Phone*

Participant #3 E-mail

School*

Grade*

Select Youth Program*

4th-6th Grade Youth Program - Temple Aliyah Member - $75

4th-6th Grade Youth Program - Non-Member - $125

7th-8th Grade Teen Program - Temple Aliyah Member - $125

7th-8th Grade Teen Program - Non-Member - $175

9th-12th Grade Teen Program - Temple Aliyah Member - $125

9th-12th Grade Teen Program - Non-Member - $175

Disneyland Day 2014 (Grades 4-12)*

Yes, I would like to go to Disneyland on August 31 - $90

No, I am not interested in going to Disneyland - $0

Medical/Transportation Form for Participant 3

I/we understand that if my child/teen is present at any KADIMA/USY/CIT event, that he/she is attending with my/our consent and permission to the Youth Department and its employees and agen ts to take my children on field trips and programs; and do hereby release its agents, officers, and employees from any and all liability arising from my/our child's/teen/s participation. In case of accident/illness, the Youth Department representatives have my permission to obtain proper aid (hospitalization, x-ray, etc.) deemed necessary by a doctor and I/we agree to pay all expenses incurred. Every attempt will be made to reach the child's parents and/or doctor for any emergency arising.*

Type your name in the box above for your electronic signature.

Medical Insurance Company*

Policy/Group Number*

Insurance Company Address*

Street AddressAddress Line 2CityStateZIP Code

Insurance Company Phone*

Personal Physician Name*

FirstLast

Personal Physician Phone*

The information on this form is accurate, complete, and all-inclusive, to the best of my knowledge. I understand the importance of keeping this information accurate and agree to contact the Temple Aliyah Director of Youth and Teen Engagement prior to any program my child/teen will attend if there is a change of any kind whatsoever in his/her medical condition.*

Type your name in the box above for your electronic signature.

List all medications currently taken on a regular basis and reasons for taking:*

Explain all other medical problems/conditions of which we should be aware:*

List any allergies to food, drugs, plants, insects, etc.:*

I acknowledge and accept USY/KADIMA/CIT's policies to use licensed drivers over the age of 21 at all times. With full understanding of the policy and the risks involved, I give permission for my child/teen to ride in a proply insured vehicle driven by a licensed driver over the age of 21.*

Type your name in the box above for your electronic signature.

I consent and give permission for my USYer/KADIMAnik/CIT to attend and participate in all trips and activities arranged by Temple Aliyah and Far West USY/KADIMA/CIT for which he/she is registered. I certify that my USYer/KADIMAnik/CIT is physically and psychologically able to participate in all such activities. In case of emergency, I authorize you, as my agent, and at my sole cost and expense, to engage appropriate healthcare providers to administer, prescribe and/or direct administration of any medication, other medical treatment, care, surgery, hospitalization or medical procedures and services deemed appropriate under the circumstances, if you are not able to timely contact me for instructions.*

Type your name in the box above for your electronic signature.

I expressly release and indemnify Temple Aliyah and it's officers, directors, agents and employees, and hold Temple Aliyah and its officers, directors, agents and employees free and harmless, from any and all liability, charged, claims, costs and expenses of eery kinds and nature whatsoever, including reasonable attorney fees, in connection with acceptance and participation of my USYer/KADIMAnik/CIT in Temple Aliyah's activities. This release and indemnification is unconditional and without reservations of any kind for such acts or omissions that arise out of your intentional or negligent wrongdoing, and where there is no fault by my USYer/KADIMAnik/CIT. I am fully responsible if I fail to disclose any pertinent information.*

Type your name in the box above for your electronic signature.

I allow Temple Aliyah to use any photographs/videos of my children taken during any Temple Aliyah/Far West USY sponsored programs/events for usage in promotional aspects.

Optional: Type your name in the box above for your electronic signature.